After 4,000 damage-control surgeries: Are we doing more damage?

Abstract

The overall utility of damage control laparotomy and its volume outcomes in patients with trauma is unknown on a national level. This study aims to identify the effect of increasing damage control laparotomy proportion on the outcomes of hemorrhaging adult trauma patients. We performed a 5-year (2017-2021) retrospective analysis of American College of Surgeons Trauma Quality Improvement Program. Adult patients (≥18 years) undergoing damage control laparotomy were included. Using facility key identifiers, trauma centers were stratified into tertiles on the basis of the damage control laparotomy to total laparotomy ratio into low, middle, and high proportion trauma centers. Primary outcomes were rates of major complications and mortality. Secondary outcomes were hospital and intensive care unit lengths of stay. Descriptive statistics and multivariable regression analyses were performed. A total of 4,034 patients with damage control laparotomy were managed at 82 trauma centers. The mean age was 40 years, and 76.6% were male. The mean shock index was 1.1 and median Glasgow Coma Scale score was 14. The median Injury Severity Scale score was 26, with no difference among the study groups. Overall, the damage control laparotomy proportion increased over time: (2017 [6%], 2018 [7%], 2019 [8%], 2020 [8%], 2021 [10%], P < .001). The median number of damage control laparotomies performed over 5 years was 45 at low proportion, 51 at middle proportion, and 59 at high proportion trauma centers. The mortality and major complications rates were 32.4% and 36%, respectively. On multivariable regression analysis, an increasing damage control laparotomy proportion was independently associated with greater rates of major complications and longer hospital length of stay. Nearly one-third of patients whose abdomen was left open could not survive their index admission, with centers practicing more damage control laparotomy associated with a greater risk of major complications and longer hospital length of stay. Significant differences despite comparable injury severity highlight the need for standardization of damage control laparotomy use among adult patients with hemorrhaging trauma.